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Forgotten vaginal pessary retrieved after 35 and 24 years of insertation: two case reports.

INTRODUCTION: Vaginal pessary placement for the management of genital prolapse is a practice that has been described since the time the ancient Greeks. Hippocrates described the use of Pomegranates soaked in vinegar as vaginal pessaries. Reported material used as vaginal pessaries included fruits, bronze cotton, wool and linen. Most of these materials were in ball oval or ring form. [1] Rubber was discovered in the 18th century, and was found to be more suitable for vaginal placement. In the middle of 20th century, rubber was replaced by plastic. More recently, silicon has replaced other materials for vaginal pessaries and approximately 20 types of either supportive or space filling pessaries are used worldwide. [2] Vaginal pessaries still have a role in the management of uterine prolapse, particularly in elderly patients. However, they are known to cause serious complications if proper care is not taken. Although surgery is the definitive treatment for severe uterine prolapse, pessaries can give satisfactory results in women who wish or need to avoid surgery [3].

Vaginal foreign body is a rare entity, particularly when detected 35 years after its insertion. The associated erosion and granulation over the vagina make its detection difficult. A high index of suspicion can help arrive in a diagnosis of such foreign bodies in women's body who present with foul smelling bloody discharge.

CASE 1: An 84-year-old postmenopausal woman presented with foul smelly vaginal discharge and occasional blood-stained discharge per vaginum for the last one month. She was referred to the department of gynecological oncology as she was suspected to suffer from cancer of cervix. She is para 5 with all home deliveries without medical assistance. Nor the patient or her attendants were able to recall the event when pessary was applied on her. On further enquiries, the attendants reported that few years after the last child birth she had uterine prolapse and may be the doctor in their village treated her.

Per speculum examination revealed an atrophic shortened vagina. A brown to blackcoloured ring pessary impacted in the vagina with erosion and granulation in the mid vagina, mucopurulent and blood stained discharge was seen.

On per vaginal examination, an irregular rim of hard structure was felt in the mid vagina. The examining finger could be negotiated through the rim upto the cervix that appeared normal. An ultrasonographic evaluation showed a ring shaped object in the vaginal area without any other abnormality.

The ring pessary was dislodged and removed with some difficulty and there was little oozing from the vagina. Vagina was irrigated with Povidine-iodine and vagina was packed with a pack soaked in Povidine-iodine. The pack was removed after twelve hours and there was no bleeding from the vagina. As she had vaginitis and trauma during removal she was given a course of antibiotics for five days.

CASE 2: Another 67-year-old postmenopausal woman presented with foul smelly vaginal discharge and bleeding per vaginum for the last one month. She presented as postmenopausal bleeding. She is para 8 with all home deliveries. Attendants of this patient also were not able to recall the event when pessary was applied on her.

Per speculum examination revealed an atrophic vagina. A dirty white-coloured ring pessary was impacted in the vagina with erosion and mucopurulent blood stained discharge.

On per vaginal examination, an irregular rim of hard structure was felt in the vagina. The examining finger could be negotiated through the rim upto the cervix that appeared normal. The ring pessary was dislodged and removed with some difficulty and there was bleeding from the vagina.

Vagina was irrigated with Povidine-iodine and vagina was packed with a pack soaked in Povidine-iodine. The pack was removed after 24 hours and there was slight bleeding from the vagina. As she had vaginitis and trauma during removal she was given a course of antibiotics for seven days.

DISCUSSION: In developing countries, pelvic organ prolapse is a very common cause of reproductive morbidity among women. Most women do not seek medical attention due to shyness, lack of family support or poverty. There are a few cases of impacted ring in -situ for years [4].

Vaginal pessaries are devices of varying composition (rubber, clear plastic, silicone, or soft plastic with internal mouldable steel reinforcement) that serve to reposition and support prolapsed genitourinary organs [5].

Although forgotten foreign bodies in vagina in adults are rare, there have been several cases of forgotten foreign bodies in vagina in adult [6,7,8,9] and majority of cases of foreign body are found in children [10,11]. Toys, metallic glasses, screws, hair sprays, plastic covers and drinking glass etc. have been found to be into the vagina. Serious complications like fistula formation [8], and bowel obstruction [9]have been reported with retained foreign body in vagina. There are reported cases of rectovaginal fistula, developing secondary to a forgotten vaginal pessary [12,13,14].

Russell [15] reported seeing patients with complications such as a rectovaginal fistula, vaginal cancer or chronic vaginitis. Other complications are incarceration, ulceration and metaplasia [16], intestinal obstruction [17,18,19] urosepsis and hydronephrosis [20,21,22]. Jain et al reported two cases of vaginal cancer associated with pessary use [23].

Removal of the foreign bodies which may be impacted in the vagina and associated with erosion and granulation tissue can be difficult and traumatic. It can be removed under sedation and vaginal trauma and bleeding can be immediate problems associated with the forceful removal of the foreign bodies from the vagina. Irrigation with an antiseptic solution and packing with a pad can be a solution to these problems. These cases have to be differentiated from local conditions such as carcinoma cervix, vaginal cancers, etc.

Vaginal pessaries are not routinely used on long--term basis in developed countries because of success and advances of surgical treatment of Pelvic organ prolapse (POP). A recent study revealed that 62.5% of women with advanced POP continued to use a pessary and avoided surgery after a successful pessary fitting [24] an. In woman who are poor surgical candidates or refuse surgical repair for symptomatic POP, a vaginal pessary is an acceptable first line option. More information about use of vaginal pessaries should be given to patients or their care givers, so that they can make informed decisions about treatment.

This unusual case draws attention to the fact that foul-smelling vaginal discharge in elderly women should arouse suspicion of a foreign body. If somebody gives history of uterine prolapse and foul smelly discharge for long, a suspicion of forgotten ring pessary should be a priority. As these women remain unaware of the presence of a foreign body in the vagina or have forgotten about the insertion of a ring in the vagina, they do not usually seek any medical attention.

REFERENCES:

[1.] Bash KI: Review of vaginal pessaries. Obstet Gynecol Surv 2000;55:455-460.

[2.] Vierhout ME: The use of pessaries in vaginal prolapse. Eur J Obstet Gynaecol Reprod Biol 2004;117:4-9.

[3.] Zeitlin MP, Lebher TB. Pessaries in the geriatric patient. J Am Geriatr Soc 1992;40: 635-39.

[4.] Marahalta RK, Shah A: Genital prolapse in women of Bhaktapur, Nepal. Nepal Med Coll J 2003;5:31-33.

[5.] Roberge J, Keller C, Garfinkel M. Vaginal pessary-induced mechanical bowel obstruction. J Emerg Med 2001;20: 367-70.

[6.] Malatyalioglu E, Alper T, Kokoo. An intravaginal foreign body of over 25 years' duration. Acta Obstet Gynecol Scand 1999: 78;616-17.

[7.] Nwosu EC, Rao S, Igweike C, Hamed H. Foreign objects of long duration in the adult vagina. J Obstet Gynaecol 2005;25(7):737-39.

[8.] Biswas A, Das HS. An unusual foreign body in the vagina producing vesicovaginal fistula. J Indian Med Assoc 2002;100(4):257-59.

[9.] Puneet, Khanna A, Khanna AK. Intravaginal foreign body--a rare cause of large bowel obstruction. J Indian Med Assoc 2002;100(11):671.

[10.] Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health 2004; 40(4):205-7.

[11.] Dahiya P, Agarwal U, Sangwan K, Chauhan M. Long retained intravaginal foreign body: a case report. Arch Gynecol Obstet 2003;268(4): 323-24.

[12.] Hanavadi S, Durham-Hall A, Oke T, Aston N. Forgotten vaginal pessary eroding into rectum. Ann R Coll Surg Engl 2004;86 (6): 18-19.

[13.] Ray A, Esen U, Nwabineli J. Iatrogenic vesico-vaginal fistula caused by shelf pessary. J Obstet Gynaecol 2006;26 (3): 275-76.

[14.] Kankam OK, Geraghty R. An erosive pessary. J R Soc Med 2002;95(10): 507.

[15.] Russell JK. The dangerous vaginal pessary. BMJ 1961; ii: 1595-97.

[16.] Poma PA. Non surgical management of genital prolapse-a review and recommendation for clinical practice. J Reprod Med 2000;45: 789-97

[17.] Lukowski I. A rare case of mechanical obstruction, occlusion of the intestine due to pessary. Pol Tyg Lek 1971;26: 1202-3.

[18.] Ott R, Richter H, Behr J, Scheele J. Small bowel prolapse and incarceration caused by vaginal ring. Br J Surg 1993;80: 1157.

[19.] Roberge RJ, Keller C, Garfinkel M. Vaginal pessary-induced mechanical bowel obstruction. J Emerg Med 2001;20(4):367-70.

[20.] Meinhardt W, Schnitemaker NW, Smeets MJ, Venema PL. Bilateral hydronephrosis with urosepsis due to neglected pessary. Scand J Urol Nephrol 1993;27: 419-20.

[21.] Dasgupta P, Booth CM. Uremia due to ureteric obstruction of a solitary kidney by a vaginal pessary. Scand J Urol Nephrol 1996;30: 493-94.

[22.] Duncan LE, Foltzer M, O'Hearn M, et al. Unilateral hydronephrosis, pyelonephritis, and bacteremia caused by a neglected vaginal ring pessary. J Am Geriatr Soc 1997;45: 1413-14.

[23.] Jain A, Majoko F, Freites O. How innocent is the vaginal pessary? Two cases of vaginal cancer associated with pessary use. J Obstet Gynaecol 2006;26 (8): 829-30.

[24.] Powers K, Lazarou G, Wang A, et al: Pessary use in advanced pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:160-164.

AUTHORS:

(1.) Sangeeta Pankaj

(2.) Vijayanand Choudhary

(3.) Rajesh Kumar Singh

(4.) Kumari Nutan

(5.) Sumit Kumar

PARTICULARS OF CONTRIBUTORS:

(1.) Assistant Professor, Department of Gynaecological Oncology, RCC, Indira Gandhi Institute of Medical Sciences, Patna.

(2.) Assistant Professor, Department of Pathology, Indira Gandhi Institute of Medical Sciences, Patna.

(3.) Associate Professor, Department of Gynaecology, RCC, Indira Gandhi Institute of Medical Sciences, Patna.

(4.) Senior Resident, Department of Gynaecology, Indira Gandhi Institute of Medical Sciences, Patna.

(5.) DNB Student, Department of Gynaecology, Indira Gandhi Institute of Medical Sciences, Patna.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Sangeeta Pankaj, Assistant Professor, Gynaecological Oncology, RCC, Indira Gandhi Institute of Medical Sciences, Patna.

Email-sangeetapankaj@yahoo.co.in

Date of Submission: 06/09/2013.

Date of Peer Review: 07/09/2013.

Date of Acceptance: 12/09/2013.

Date of Publishing: 20/09/2013
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Article Details
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Title Annotation:CASE REPORT
Author:Pankaj, Sangeeta; Choudhary, Vijayanand; Singh, Rajesh Kumar; Nutan, Kumari; Kumar, Sumit
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Sep 23, 2013
Words:1772
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